- Paresh is a GP, medical director of a network of large integrated health centres in Canberra, visiting fellow at the Australian Primary Health Care Research Institute (ANU) and at Keele Univeristy (UK), and implementation adviser to Australian Capital Territory’s Medicare Local.
A health foundation research scan (2) suggests three key causes of harm in primary care: clinical complexity, systems issues and human factors. Paresh Dawda’s Human Reliability in Primary Care blog brought to you by BMJ Quality, focuses on the human factors element.
We hear lots about patient safety, but the voice of primary care is not heard as loudly as that from the acute sector. Primary care is equally prone to patient safety threats and risks. The research is limited, but estimates of patient safety incidents are estimated at between 0.004-240.0 per 1000 primary care consultations with 45%-76% of all “errors” thought to be preventable.(1)
Spend a few minutes and reflect on:
• Interruptions during your consultations
• How alert you feel towards the end of a three hour session compared to the beginning
• How often you find that something you need, e.g. a form, a piece of equipment is not there and you have to go looking for it
• How often do you experience communication related misunderstandings between yourself and others e.g. receptionists, nurses, care home staff, other doctors or patients.
These are just a few everyday common occurrences. Of course, they do not always lead to patient harm but still they have the potential to do so. Clinical human factors are about “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.” (3) Put another way, “human factors are all the things that make us different from logical, completely predictable machines. In simple terms they are all those things that enhance or reduce human performance.” (3)
The delivery of healthcare relies on us, as humans, interacting in a multitude of ways with the health care system; whether it is operating our clinical computer system, undertaking a procedure, or talking with colleagues or patients. Moreover, it also encompasses the way our patients relate to the system since those same human factors that affect us also affect our patients. Recognising and appreciating this is the first step in enhancing clinical performance. The second step is to understand how, as humans, we interact with other components of the system and carry out tasks. The third is to understand the multiple variables that impact on the quality of that interaction and strategies to reduce that impact. These may be personal factors such as fatigue, illness, irregular work patterns, and reliance on memory, or they may be environmental factors such as distractions (through noise, motion, clutter, heat, lighting), poorly designed procedures, or simply lack of training.
When I was on the faculty of the NHS Institute’s (now NHS IQ) safer care faculty, we had a simple mantra: “make it easier to do the right thing, make it harder to do the wrong thing.” However, in order to improve human reliability we have to go a step further and appreciate the inevitability of human error. Therefore we also have to put in place mechanisms to spot and stop errors before they become a safety threat.
My first purposeful application of this understanding was in a project implementing the NICE guidelines on assessing febrile children (CG160) (4), and in particular the clinical assessment of febrile children, a key priority for implementation. One of the NICE recommendations is to “measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever.” On the face of it this is a simple recommendation, but to reliably implement it required many human factor related interventions. One simple example is a prompt to measure the four items. We knew from our data that the temperature was beings checked 70% of the time. Therefore, associating the reminder prompt with the task of checking the temperature would potential yield positive results. The task of checking the temperature mostly entails using a tympanic thermometer and then reading the temperature on the LCD screen, so a prompt at this point would achieve the objective. Just as with any other change idea, the model for improvement can then be used to test out the idea and refine it using iterative cycles.
More information on this and other examples from the project are given in the video and in either the NICE shared learning example or the Clinical Human Factors Group’s ‘How to Guide’ ( ), whose website hosts resources on clinical human factors.
The Health Foundation’s research scan concluded that “the potential for improving safety in primary care is significant, not least because of the volume of consultations taking place, the complexity of the interactions involved and the uncertainty associated with providing care in the community.” Applying clinical human factors is a powerful mechanism to achieve that improvement.
Paresh has worked in UK general practice, is an experienced trainer, and developed, delivered and coached on leadership, quality and patient safety improvement programs for NHS Institute for Innovation and Improvement before migrating to Australia in 2012. He is a member of WONCA’s working party on quality and safety, leading a chapter on transitions of care for WHO and on the editorial board of the Australasian Medical Journal. Paresh has published articles on quality and patient safety improvement and has delivered presentations and workshops at national and international conferences. Watch more here.
If you are working to improve quality in healthcare, you may wish to submit your work to BMJ Quality Improvement Reports. To find out how, go to quality.bmj.com.
References
1. Makeham M, Dovey S, Runciman W, Larizgoitia I. Methods and Measures used in Primary Care Patient Safety Research. Review of the literature. 2008
2. Research scan: Improving safety in primary care [Internet]. Health Foundation; 2011 [cited May 2014 ]. Available from: http://www.health.org.uk/public/cms/75/76/313/3077/Improving%20safety%20in%20primary%20care.pdf?realName=VzT40H.pdf
3. Towards a working definition of human factors in healthcare [Internet]. Clinical Human Factors Group[cited May 2014]. Available from: http://chfg.org/definition/towards-a-working-definition-of-human-factors-in-healthcare
4. Feverish illness in children (CG160) [Internet]. NICE; 2013 [cited 2014 May]. Available from: